Form Instructions

The Town of Stafford is partnering with local health districts and providers to offer free COVID-19 vaccination clinics for Stafford residents 18+. Please complete this form to get notified when vaccination appointments become available. The information you enter will only be used for purposes of scheduling your vaccination, and will be kept private.

Eligible groups are based on the current State of Connecticut COVID-19 AGE vaccination phases. For current eligibility details, visit portal.ct.gov/vaccine-portal/COVID-19-Vaccination-Phases. Additionally, vaccination registration fields below reflect VAMS enrollment issued/required by the State.

Please note: 
Appointments are offered in the order in which they are received. Following submission of this form, you will be contacted when an appointment become available. Please know that calls to residents to set up appointments might come just days before the clinic to assure supply is in hand.

The Town of Stafford utilizes trained volunteers, medical professionals, and emergency management personnel to safely operate local clinics. 

This is a town-hosted clinic for first vaccine doses.

Vaccination supply is limited and residents can - and are encouraged - to still go through VAMS and chose to be vaccinated at any available site: portal.ct.gov/vaccine-portal

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* 1. First Name

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* 2. Last Name

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* 3. Gender

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* 4. Date of Birth

Date

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* 5. Race

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* 6. Ethnicity

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* 7. Street Address

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* 8. City

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* 9. Cell Phone

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* 10. Alternative Phone

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* 11. Eligible Occupation or Age Eligibility Requirement

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